St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

LUTONIX DRG CT BL 4MMX80MMX75CM

Facility

$3,200.00

Service Code	HCPCS C2623
Hospital Charge Code	40004801
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$3,360.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,760.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,600.00
Rate for Payer: Aetna Government	$1,600.00
Rate for Payer: Brighton Health Commercial	$1,920.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,600.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,840.00
Rate for Payer: EmblemHealth Commercial	$1,600.00
Rate for Payer: Fidelis Medicare Advantage	$3,360.00
Rate for Payer: Group Health Inc Commercial	$1,600.00
Rate for Payer: Group Health Inc Medicare	$1,120.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,600.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,080.00

LUTONIX DRG CT BL 5MMX100MMX130MM

Facility

$3,200.00

Service Code	HCPCS C2623
Hospital Charge Code	40004742
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$3,360.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,760.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,600.00
Rate for Payer: Aetna Government	$1,600.00
Rate for Payer: Brighton Health Commercial	$1,920.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,600.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,840.00
Rate for Payer: EmblemHealth Commercial	$1,600.00
Rate for Payer: Fidelis Medicare Advantage	$3,360.00
Rate for Payer: Group Health Inc Commercial	$1,600.00
Rate for Payer: Group Health Inc Medicare	$1,120.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,600.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,080.00

LUTONIX DRG CT BL 5MMX100MMX130MM

Facility

$3,200.00

Service Code	HCPCS C2623
Hospital Charge Code	40004742
Hospital Revenue Code	278
Min. Negotiated Rate	$1,600.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,600.00

LUTONIX DRG CT BL 5MMX100MMX75CM

Facility

$3,200.00

Service Code	HCPCS C2623
Hospital Charge Code	40004806
Hospital Revenue Code	278
Min. Negotiated Rate	$1,600.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,600.00

LUTONIX DRG CT BL 5MMX100MMX75CM

Facility

$3,200.00

Service Code	HCPCS C2623
Hospital Charge Code	40004806
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$3,360.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,760.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,600.00
Rate for Payer: Aetna Government	$1,600.00
Rate for Payer: Brighton Health Commercial	$1,920.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,600.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,840.00
Rate for Payer: EmblemHealth Commercial	$1,600.00
Rate for Payer: Fidelis Medicare Advantage	$3,360.00
Rate for Payer: Group Health Inc Commercial	$1,600.00
Rate for Payer: Group Health Inc Medicare	$1,120.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,600.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,080.00

LUTONIX DRG CT BL 5MMX120MMX130MM

Facility

$3,500.00

Service Code	HCPCS C2623
Hospital Charge Code	40004743
Hospital Revenue Code	278
Min. Negotiated Rate	$1,750.00
Max. Negotiated Rate	$1,750.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,750.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,750.00

LUTONIX DRG CT BL 5MMX120MMX130MM

Facility

$3,500.00

Service Code	HCPCS C2623
Hospital Charge Code	40004743
Hospital Revenue Code	278
Min. Negotiated Rate	$1,225.00
Max. Negotiated Rate	$3,675.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,925.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,750.00
Rate for Payer: Aetna Government	$1,750.00
Rate for Payer: Brighton Health Commercial	$2,100.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,750.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,012.50
Rate for Payer: EmblemHealth Commercial	$1,750.00
Rate for Payer: Fidelis Medicare Advantage	$3,675.00
Rate for Payer: Group Health Inc Commercial	$1,750.00
Rate for Payer: Group Health Inc Medicare	$1,225.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,750.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,750.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,275.00

LUTONIX DRG CT BL 5MMX150MMX130MM

Facility

$3,800.00

Service Code	HCPCS C2623
Hospital Charge Code	40004744
Hospital Revenue Code	278
Min. Negotiated Rate	$1,330.00
Max. Negotiated Rate	$3,990.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2,090.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,900.00
Rate for Payer: Aetna Government	$1,900.00
Rate for Payer: Brighton Health Commercial	$2,280.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,900.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,185.00
Rate for Payer: EmblemHealth Commercial	$1,900.00
Rate for Payer: Fidelis Medicare Advantage	$3,990.00
Rate for Payer: Group Health Inc Commercial	$1,900.00
Rate for Payer: Group Health Inc Medicare	$1,330.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,900.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,900.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,470.00

LUTONIX DRG CT BL 5MMX150MMX130MM

Facility

$3,800.00

Service Code	HCPCS C2623
Hospital Charge Code	40004744
Hospital Revenue Code	278
Min. Negotiated Rate	$1,900.00
Max. Negotiated Rate	$1,900.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,900.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,900.00

LUTONIX DRG CT BL 5MMX40MMX130MM

Facility

$3,200.00

Service Code	HCPCS C2623
Hospital Charge Code	40004739
Hospital Revenue Code	278
Min. Negotiated Rate	$1,600.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,600.00

LUTONIX DRG CT BL 5MMX40MMX130MM

Facility

$3,200.00

Service Code	HCPCS C2623
Hospital Charge Code	40004739
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$3,360.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,760.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,600.00
Rate for Payer: Aetna Government	$1,600.00
Rate for Payer: Brighton Health Commercial	$1,920.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,600.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,840.00
Rate for Payer: EmblemHealth Commercial	$1,600.00
Rate for Payer: Fidelis Medicare Advantage	$3,360.00
Rate for Payer: Group Health Inc Commercial	$1,600.00
Rate for Payer: Group Health Inc Medicare	$1,120.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,600.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,080.00

LUTONIX DRG CT BL 5MMX50MMX75CM

Facility

$3,200.00

Service Code	HCPCS C2623
Hospital Charge Code	40004803
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$3,360.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,760.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,600.00
Rate for Payer: Aetna Government	$1,600.00
Rate for Payer: Brighton Health Commercial	$1,920.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,600.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,840.00
Rate for Payer: EmblemHealth Commercial	$1,600.00
Rate for Payer: Fidelis Medicare Advantage	$3,360.00
Rate for Payer: Group Health Inc Commercial	$1,600.00
Rate for Payer: Group Health Inc Medicare	$1,120.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,600.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,080.00

LUTONIX DRG CT BL 5MMX50MMX75CM

Facility

$3,200.00

Service Code	HCPCS C2623
Hospital Charge Code	40004803
Hospital Revenue Code	278
Min. Negotiated Rate	$1,600.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,600.00

LUTONIX DRG CT BL 5MMX60MMX130MM

Facility

$3,200.00

Service Code	HCPCS C2623
Hospital Charge Code	40004740
Hospital Revenue Code	278
Min. Negotiated Rate	$1,600.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,600.00

LUTONIX DRG CT BL 5MMX60MMX130MM

Facility

$3,200.00

Service Code	HCPCS C2623
Hospital Charge Code	40004740
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$3,360.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,760.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,600.00
Rate for Payer: Aetna Government	$1,600.00
Rate for Payer: Brighton Health Commercial	$1,920.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,600.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,840.00
Rate for Payer: EmblemHealth Commercial	$1,600.00
Rate for Payer: Fidelis Medicare Advantage	$3,360.00
Rate for Payer: Group Health Inc Commercial	$1,600.00
Rate for Payer: Group Health Inc Medicare	$1,120.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,600.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,080.00

LUTONIX DRG CT BL 5MMX60MMX75CM

Facility

$3,200.00

Service Code	HCPCS C2623
Hospital Charge Code	40004804
Hospital Revenue Code	278
Min. Negotiated Rate	$1,600.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,600.00

LUTONIX DRG CT BL 5MMX60MMX75CM

Facility

$3,200.00

Service Code	HCPCS C2623
Hospital Charge Code	40004804
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$3,360.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,760.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,600.00
Rate for Payer: Aetna Government	$1,600.00
Rate for Payer: Brighton Health Commercial	$1,920.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,600.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,840.00
Rate for Payer: EmblemHealth Commercial	$1,600.00
Rate for Payer: Fidelis Medicare Advantage	$3,360.00
Rate for Payer: Group Health Inc Commercial	$1,600.00
Rate for Payer: Group Health Inc Medicare	$1,120.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,600.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,080.00

LUTONIX DRG CT BL 5MMX80MMX130MM

Facility

$3,200.00

Service Code	HCPCS C2623
Hospital Charge Code	40004741
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$3,360.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,760.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,600.00
Rate for Payer: Aetna Government	$1,600.00
Rate for Payer: Brighton Health Commercial	$1,920.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,600.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,840.00
Rate for Payer: EmblemHealth Commercial	$1,600.00
Rate for Payer: Fidelis Medicare Advantage	$3,360.00
Rate for Payer: Group Health Inc Commercial	$1,600.00
Rate for Payer: Group Health Inc Medicare	$1,120.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,600.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,080.00

LUTONIX DRG CT BL 5MMX80MMX130MM

Facility

$3,200.00

Service Code	HCPCS C2623
Hospital Charge Code	40004741
Hospital Revenue Code	278
Min. Negotiated Rate	$1,600.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,600.00

LUTONIX DRG CT BL 5MMX80MMX75CM

Facility

$3,200.00

Service Code	HCPCS C2623
Hospital Charge Code	40004805
Hospital Revenue Code	278
Min. Negotiated Rate	$1,600.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,600.00

LUTONIX DRG CT BL 5MMX80MMX75CM

Facility

$3,200.00

Service Code	HCPCS C2623
Hospital Charge Code	40004805
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$3,360.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,760.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,600.00
Rate for Payer: Aetna Government	$1,600.00
Rate for Payer: Brighton Health Commercial	$1,920.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,600.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,840.00
Rate for Payer: EmblemHealth Commercial	$1,600.00
Rate for Payer: Fidelis Medicare Advantage	$3,360.00
Rate for Payer: Group Health Inc Commercial	$1,600.00
Rate for Payer: Group Health Inc Medicare	$1,120.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,600.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,080.00

LUTONIX DRG CT BL 6MMX100MMX130MM

Facility

$3,200.00

Service Code	HCPCS C2623
Hospital Charge Code	40004748
Hospital Revenue Code	278
Min. Negotiated Rate	$1,600.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,600.00

LUTONIX DRG CT BL 6MMX100MMX130MM

Facility

$3,200.00

Service Code	HCPCS C2623
Hospital Charge Code	40004748
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$3,360.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,760.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,600.00
Rate for Payer: Aetna Government	$1,600.00
Rate for Payer: Brighton Health Commercial	$1,920.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,600.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,840.00
Rate for Payer: EmblemHealth Commercial	$1,600.00
Rate for Payer: Fidelis Medicare Advantage	$3,360.00
Rate for Payer: Group Health Inc Commercial	$1,600.00
Rate for Payer: Group Health Inc Medicare	$1,120.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,600.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,080.00

LUTONIX DRG CT BL 6MMX100MMX75CM

Facility

$3,200.00

Service Code	HCPCS C2623
Hospital Charge Code	40004810
Hospital Revenue Code	278
Min. Negotiated Rate	$1,600.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,600.00

LUTONIX DRG CT BL 6MMX100MMX75CM

Facility

$3,200.00

Service Code	HCPCS C2623
Hospital Charge Code	40004810
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$3,360.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1,760.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1,600.00
Rate for Payer: Aetna Government	$1,600.00
Rate for Payer: Brighton Health Commercial	$1,920.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1,600.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1,840.00
Rate for Payer: EmblemHealth Commercial	$1,600.00
Rate for Payer: Fidelis Medicare Advantage	$3,360.00
Rate for Payer: Group Health Inc Commercial	$1,600.00
Rate for Payer: Group Health Inc Medicare	$1,120.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1,600.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1,600.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2,080.00

Know your out-of-pocket cost for care.

All Charges